Saudi Journal of Medical and Pharmaceutical Sciences

Abbreviated Key Title: Saudi J Med Pharm Sci

ISSN 2413-4929 (Print) | ISSN 2413-4910 (Online)
Scholars Middle East Publishers, Dubai, United Arab Emirates
Journal homepage: https://saudijournals.com

Original Research Article

HsCRP (High-Sensitivity C - reactive protein) and its Association with

Short Term Prognosis1* Following Ischaemic
2
Stroke 3 4
Mohammed Momenuzzaman Khan , Farhana Younus , Mohammad Ibrahim Hossain , Ayesha Tabassum Swarna ,
Nelson Taposh Mondal5, Sajal Kumar Shil6
1
Associate Professor, Department of Neurology, Enam Medical College, Savar, Dhaka, Bangladesh
2
Consultant, Department of Ophthalmology, Bangladesh EYE Hospital, Dhaka, Bangladesh
3
Assistant Professor, Department of Physical Medicine and Rehabilitation, Enam Medical College, Savar, Dhaka, Bangladesh
4
Medical Officer, BRAC, Bangladesh
5
Associate Professor, Department of Medicine, Enam Medical College, Savar, Dhaka, Bangladesh
6
Assistant Professor, Department of Neuro-Medicine, Kumudini Women’s Medical College, Tangail, Bangladesh

DOI: 10.36348/sjmps.2022.v08i04.001 | Received: 26.02.2022 | Accepted: 29.03.2022 | Published: 06.04.2022

*Corresponding author: Mohammed Momenuzzaman Khan
Associate Professor, Department of Neurology, Enam Medical College, Savar, Dhaka, Bangladesh

Abstract
Introduction: Stroke is a major cerebrovascular disease is one of the most common Neurological diseases. It is the
second leading cause of death worldwide. Cerebrovascular disease threatening human health and life with high
morbidity, disability and mortality. Major risk factors of ischaemic strokes are hypertension, diabetes, and dyslipidaemia.
High sensitivity C-reactive protein (HsCRP) is an inflammatory marker which appears to be a strong predictor of risk
factor and prognostic marker of Ischaemic stroke. Objective: To find the acute course of HsCRP and its association with
short term prognosis following Ischaemic stroke. Methods: A Cross sectional observational study at Dept. of Neurology,
Enam Medical College Hospital, Savar, Dhaka, Bangladesh From March 2020 to April 2021. Total number of subjects in
this study were 101 with power 80% (persons aged 30 years & above; both male and female). Both sexes and their
plasma high sensitivity C-reactive protein (HsCRP) level was measured within 48 hours of admission and on the 5th day
after admission. Results: The study showed that the level of HsCRP did not change significantly when measured within
48 hours of onset of Ischaemic stroke and on 5th day after stroke (p=0.335) - the prognosis and severity remained same
when followed for 5 days. It, also, showed that the level of CRP ≥ 3 within 48 hours of admission is associated with
increased severity and mortality of stroke (Z=14.4; p<0.0001). Conclusion: HsCRP level provides rapid and reliable
information regarding severity & prognosis in patients with Ischaemic stroke. The level of HsCRP does not change
significantly when measured within 48 hours of onset of Ischaemic stroke and on 5th day after stroke. Also, the level of
CRP on 5th day was same as within 48 hours of stroke - the prognosis and severity remained same. If confirmed by
larger, longitudinal studies this association may be used as a tool to assess the severity and prognosis in a patient with
Ischaemic strokes.
Keywords: HsCRP, Ischaemic Stroke, Short Term Prognosis.
Copyright © 2022 The Author(s): This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International
License (CC BY-NC 4.0) which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original
author and source are credited.

of vascular origin‟. Stroke or Cerebrovascular accident

INTRODUCTION is the second most leading cause of death worldwide
Stroke is a major cerebrovascular disease is [2]. Ischaemic stroke comprises 85 percent of all
one of the most common Neurological diseases. It is the strokes; rest are due to Haemorrhagic stroke (15
second leading cause of death worldwide. percent). Hypertension, Diabetes, Dyslipidaemia, and
Cerebrovascular disease threatening human health and Smoking are major risk factors of Ischaemic stroke.
life with high morbidity, disability and mortality [1]. Various biomarkers have been studied as risk-factors
The World Health Organisation (WHO) defines stroke and prognostic-markers for acute ischaemic Strokes.
as: 'Rapidly developing clinical signs of focal or global Creative protein (HsCRP) appears to be a strong
disturbances of cerebral function with symptoms lasting predictor of Cardio vascular and cerebrovascular risk
for 24hours or longer with no apparent cause other than factors [3]. CRP is an acute phase reactant that is
Citation: Mohammed Momenuzzaman Khan, Farhana Younus, Mohammad Ibrahim Hossain, Ayesha Tabassum Swarna, Nelson 161
Taposh Mondal, Sajal Kumar Shil (2022). HsCRP (High-Sensitivity C - reactive protein) and Its Association with Short Term Prognosis
Following Ischaemic Stroke. Saudi J Med Pharm Sci, 8(4): 161-165.
 Mohammed Momenuzzaman Khan et al; Saudi J Med Pharm Sci, April, 2022; 8(4): 161-165
exclusively synthesized in the liver in response to
inflammation. Studies have shown the role of CRP as a
predictor of outcome, severity, and mortality in Stroke
patients [4-7]. In a study it has been found that high
plasma CRP is associated with increased risk of stroke
[8]. The Framingham study has shown that HsCRP is
also used to predict future risk of stroke. Various
prospective studies have found initial CRP levels to be
higher in persons who develop stroke, ischemic heart
disease, and peripheral artery disease.
MATERIAL AND METHODS
A Cross sectional observational study at Dept.
of Neurology, Enam Medical College Hospital, Savar,
Dhaka, Bangladesh From March 2020 to April 2021.
Total number of subjects in this study were 101 with
power 80% (persons aged 30 years & above; both male
and female). Both sexes and their plasma high
sensitivity C-reactive protein (HsCRP) level were
measured within 48 hours of admission and on the 5 th
day after admission.
Inclusion criteria
1. Patients with first ever Ischaemic stroke.
2. Age more than 30 years.
3. Patients attending Emergency Department of
neurology at EMCH, within 48 hours of onset
of neurological symptoms.
Exclusion criteria
1. Patients with hg, subarachnoid hg, or
extradural hg.
2. Patients attended with neuropathic symptoms
secondary to intracranial tumor, infection,
head injury, subdural hematoma.
3. Patients attending with features of old stroke.
4. Patients attending after 48 hours of stroke.
5. Conditions associated with high CRP
elevation: fever, information, peripheral
vascular disease, acute myocardial infarction.
6. Patients attending with features of TIA
transient cerebral ischemia.

RESULTS
Table-1: Age Distribution (N=101)
Age Group (in years) Number %
30-45 13 12.87%
46-55 21 20.79%
56-65 35 34.65%
66-75 21 20.79%
≥80 11 10.89%
Total 101 100.00%

Table 1 show that the mean age (mean±s.d.)Of showed that the proportion of the age group 56- 65
the patients were 62.06±11.18 years with range of 30- years (34.65%) was significantly higher than other age
85 years. The median age was 65 years. Test proportion groups (Z=2.06; p<0.05).

Table 2: Gender Distribution (N=101)

Gender Number %
Male 65 64.35%
Female 36 35.64%
Total 101 100.0%

Table 2 show that Gender distribution of test was significantly higher than females (35.64%)
proportion showed that proportion of males (64.35%) (Z=3.96; p<0.001).

Table-3: High sensitivity CRP within 48hours (N=101)

HsCRP within 48 hours Number %
≥3 27 26.73%
<3 74 73.26%
Total 101 100.0%

Table 3 show that High sensitivity CRP within median 1.55. 27%of the patients had higher HsCRP
48hrs.The mean HsCRP within 48hours (mean±s.d.) of (≥3) which was not statistically significant (p>0.05).
the patients was 2.69±2.66 with range 0.6 - 12.6 and

© 2022 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 162
 Mohammed Momenuzzaman Khan et al; Saudi J Med Pharm Sci, April, 2022; 8(4): 161-165
Table-4: Highly sensitive CRP on 5th Day (N=101)
HsCRP on 5th Day Number %
≥3 26 25.74%
<3 75 74.25%
Total 101 100.0%

Table 4 shows that High sensitivity CRP on5th 25.74% of the patients had higher HsCRP (≥3) which
day: The mean HsCRP on 5th day (mean±s.d.) was was not statistically significant (p>0.05).
2.65±2.70 with range of 0.6-12.3 and median was 1.60.

Table-5: Outcome and level of HsCRP within 48 hours (N=101)

Outcome HsCRP≥ 3 (n= 27) HsCRP< 3 (n = 74) Total
Dead 7 0 7
Row % 100.0% 0.0% 100.0%
Col % 25.9% 0.0% 6.9%
Alive 21 74 95
Row % 22.3% 77.7% 100.0%
Col % 77.7% 100.0% 94.0%
Total 27 74 100
Row % 26.7% 73.3% 100.0%
Col % 100.0% 100.0% 100.0%

Table-5 show that outcome and level of
HsCRP within 48 hours: Test of proportion showed that
proportion of deaths were significantly higher for
HsCRP≥ 3 as compared to HsCRP< 3 (Z = 14.14;
p<0.0001).
DISCUSSION
The study showed that males are
predominantly affected. The age range was 30-85 years
with a mean of 62.06 years. According to data obtained
from Framingham study, incidents of stroke increase
steeply with age becoming double in each successive
decade from 55years onwards. In this study, the risk of
HsCRP ≥3 was 11.21 times more among the patients
having ≥ 55years of ages compared to patients having
≥55 years of ages compared to patients having <55years
of age. Stroke is an abrupt onset neurologic deficit due
to focal vascular cause. It is a major concern for the
community regarding disability, social and mental
burden. All patients were selected strictly and carefully
as per protocol (after satisfying inclusion and exclusion
criteria) to avoid any confounding factor of increasing
inflammatory markers (HsCRP). Ischaemic stroke is
caused mainly by atherosclerotic narrowing or
occlusion of cerebral circulation. The prevalence of
Ischaemic stroke has been increasing over the last
decade. This may be attributed to increase in life
expectancy and aging of population [9, 10].
Nevertheless, Ischaemic stroke is much less studied in
terms of its prognosis. This study was conducted to
elucidate relationship between high sensitivity C-
reactive protein (HsCRP) and Ischaemic stroke. Studies
have shown that atherosclerosis is an inflammatory
condition [11]. HsCRP is an indicator of inflammatory
response to atherosclerosis. Indians have higher
prevalence of hypertension and diabetes which puts
© 2022 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates
more risk of atherosclerosis. The elevation of CRP
following Ischaemic stroke suggests its role in
inflammation. Some studies have shown the role of
CRP as the predictor of outcome, severity and mortality
in stroke patients. In a study it has been found that high
plasma CRP concentrations are associated with
increased risk of stroke [8, 12] and its recurrence [13].
The Framingham study has shown that HsCRP is also
used to predict future risk of stroke [14]. In this study
we found that levels of acute phase proteins are stable
after stroke for at least five days. There is no significant
time trend in this period of time. Chi-square (χ2) test
showed that there was significant association between
HsCRP within 48 hours and on 5th day after acute
stroke (p=0.000001). To examine the effect of HsCRP
level, we divided the patients into two groups: low
HsCRP group (HsCRP<3mg/L) and high HsCRP group
(≥3mg/L). The risk of HsCRP≥3 on 5th day was
134.16times more among patients with HsCRP≥3
within 48 hours and the risk was significant. This
means patients with high HsCRP on 48hrs of onset of
stroke remained high on 5th day when followed. As per
Wilcoxon Signed Rank Test, there was no significant
difference between level of HsCRP within48hours and
on 5th day (p=0.335). This means level of HsCRP
remained stable over short-term course followed for 5
days. This result is supported by a study by Mitchell SV
Elkind et al. [16]. There is a crude association between
high CRP and short-term outcome which is likely
secondary to stroke severity as seen by NIHSS and
marker of inflammation HsCRP. Mechanism of CRP
elevation is not completely defined in patients with
Ischaemic stroke. Possible theory includes hyper fusion
and congestion in the nervous tissue influence secretion
of IL_6 thereby promoting CRP production by the liver
tissue. It has been found that high CRP value within 48
hours of admission, the severity of neurological
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 Mohammed Momenuzzaman Khan et al; Saudi J Med Pharm Sci, April, 2022; 8(4): 161-165
impairment was also high. As per Pearson correlation
co-efficient in this study, significant correlation was
observed between HsCRP within 48hours (r=0.616;
p=0.0001,) NIHSS on 5th day (r=0.566; p=0.0001) and 5.
NIHSS on 90th day (r=0.616; p=0.0001). So, the
patients having higher CRP within 48 hours were
significantly correlated with severity of stroke over time
followed till 90 days. Also, deaths were significantly
higher in HsCRP more than 3 times within 48 hours
(Z=14.4; p<0.0001). The association of HsCRP and 6.
Ischaemic stroke in this study may be attributed to high
prevalence of patients with hypertension and diabetes.
Previously many studies have demonstrated association
between CRP and hypertension and also with diabetes
[16]. In our study 44% of patients had hypertension, 7.
47% had diabetes, 23% had heart disease. Systolic
blood pressure if maintained<130 is favourable to
reduce the risk of stroke [17]. The mean CBG (mean
±s.d) of the patients was 160.94mg% with a range of 8.
66.422mg% and the median was 120mg%. 43%
patients had CBG >200. In previous studies it was
found that high blood glucose within 24hours is
associated with poor outcome [18]. In our study, we
found that patients who died due to Ischaemic stroke
had significantly higher blood glucose at the time of 9.
admission (212.83±137.86) than who survived
(157.37±183.85). 10.
CONCLUSION
HsCRP level provides rapid and reliable 11.
information regarding severity & prognosis in patients
with Ischaemic stroke. The level of HsCRP does not
change significantly when measured within 48 hours of 12.
onset of Ischaemic stroke and on 5th day after stroke.
Levels are not influenced by the site of infarction as
seen by CT scan of brain. Level of CRP ≥ 3 within 48
hours of admission is associated with increased severity
and mortality of stroke. Also, the level of CRP on 5th 13.
day was same as within 48 hours of stroke - the
prognosis and severity remained same. If confirmed by
larger, longitudinal studies this association may be used
as a tool to assess the severity and prognosis in a patient
with Ischaemic strokes. 14.
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